Angina pectoris is a medical terms to referring to the chest pain or discomfort by reduced blood flow to the heart muscle . it is usually a symptoms of coronary artery disease often triggered by physical or emotional stress. the treatment of angina pectoris by medication ,changes life style proper exercise.

1. • Organic nitrates
•  receptor blockers
• Calcium channel blockers

2. Coronary vessels: blood supply for the heart
1. OVERVIEW

3. Coronary atherosclerosis:
cause of cardiac ischemia

4.  Generally described as
retrosternal heavy or
gripping sensation with
radiation to left arm or neck,
provoked by exertion and
eased with rest or nitrates

5.  AP-the chief symptom of ischemic heart
disease, is due to imbalance bet O2 supply &
O2 demand of the myocardium.
 Symptoms :sudden, severe, substernal
discomfort or pain which may radiate to the
left shoulder & along the flexor surface of the
left arm.
 O2 consumption depends on preload (venous
return & streching of the heart ),& afterload
(PVR) & HR.

6.  1 Stable angina :(classical angina, angina of
effort, exertional angina)-pain is induced by
exercise or emotion, both increases O2 demand.
 2 Unstable angina ( angina at rest) : common
due to rupture of an atheromatous plaque &
platelet deposition in the coronary artery, leading
to progressive thrombosis. (here patients of
stable angina develops angina at rest )
 3 prinzmetal’angina : (variant angina) – angina
that develops at rest & is due to spasm of the
coronary arteries.

7.  O2supplydecreases
 Coronary
atherosclerosis
 Coronary
vasospasm
 Coronary
thrombosis
 O2 demand
increases
 Increase HR
 Ventricular
hypertrophy
 Increased
ventricular
contractility
 Increased
ventricular wall
tension.

8.  Increasing O2 supply
 Remove athero.
Plaque
 Remove vasospasm
by drugs –
CCBS,NITRATES
 Break the thrombi-
strepto. Uro.
 Prevent thrombi -
aspirin
 Decreasing O2
demand
 By reducing
workload as preload
–nitrates
 Afterload –CCBS
 Decreases HR &
contractility -BBS

9. 1. Nitrates: Nitroglycerine, ISDN, ISMN.
2. CCBS : Verapamil, Diltiazam, Nifedipine,
Amlodipine.
3. BBS: Propranolol, Atenolol.
4. Potassium channel openers: Nicorandil
5. Miscellaneous: low dose aspirin,
dipyridamole, trimetazidine.

10.  Nitrates are prodrugs & they release nitric
oxide (NO).
 Nitrates are mainly venodilators, also cause
arteriolar dilatation & as a result reduce both
Preload & Afterload.

12. NITRATES
Denitrated in the smooth muscle cell
Releases nitric oxide
Stimulates guanylyl cyclase
Increases cGMP –This cGMP catalyses the
phosphorylation of protein kinases causing
relaxation of the smooth muscles.

14.  Nitroglycerine (NTG): quickly relieves pain by
decre. O2 requirement & incre. O2 supply to
the myocardium.
 NTGs are predominantly venodilators.
 Venodilatation reduces venous return to the
heart, thereby reduces preload.
 Arteriolar dilatation reduces PVR = decre. In
Afterload.( so decre. O2 requirement).
 In variant angina , Nitrates relieve vasospasm
due to coronary vasodilation.

15.  Nitrates cause dilatation of blood vessels in
the skin = flushing
 Dilatation of meningeal vessels =headache.
 Bronchial smooth muscles are also relaxed.

16.  Nitrates are well absorbed orally but undergo
extensive 1st-pass metabolism.
 Sublingual route =rapid onset (2 to 5 min)
but short duration of action.
 Absorption through skin is slow, so used for
prolonged effect.
 Metabolites are excreted in urine as
glucuronide derivatives.

17.  Headache ,flushing, sweating, palpitation,
weakness, postural hypotension & rashes can
occur.
 Tolerance (also cross tolerance)
 By proper dosage schedule ,tolerance can be
avoided.( 8 hr drug free interval )
 Also tolerance minimised by twice/thrice
daily dosage schedule.

18. 1. Angina: sublingual NTG are DOC.
◦ Repeated 3 tab in 15 min.
◦ LA nitrates are used orally for prophylaxis of
angina.
◦ NTG ointment may be applied over the chest.
2. Cardiac failure: as a vasodilator.
3. MI: IV NTG used for decreasing cardiac
work.
4. Biliary colic: sublingual NTG are used to
relieve biliary spasm .

19.  5 cyanide poisoning : cyanide rapidly binds to
cytochrome oxidase = inhibition of cellular
respiration & blocks the utilization of O2.
 TREATMENT:
HB METHB CYANOMETHB
iv sod thiosul.
SODIUMTHIOCYANATE
CYANIDE (rapidly ex.in uri)
CYTOCHROME OXIDASE
nitrite

20.  CCBS relax the arterioles leading to decrease
in PVR & reduction in Afterload.
 Also depress myo. Contractility thereby
reduces HR & FOC.
 This results in reduced cardiac workload & O2
consumption.
 CCBS also dilate the coronaries thereby
increases coronary blood flow.
 CCBS :Used for prophylaxis of exertional
angina.

21.  They can be combined ( except verapamil)
with BB.
 CCBS are also used in vasospastic angina
since they dilate the coronaries & relieve
vasospasm. ( preffered over nitrares.)

22.  BBS reduces the severity of attacks of
exertional angina & are useful in the
prevention of angina.
 Exercise,emotion etc. increases sympa.
Activity = incre. In HR, FOC & BP, therefor
increase in O2 consumption.
 BBS prevent angina by blocking all these
actions.
 Used for longterm prophylaxis of classical
angina& may be combined with nitrates.

23.  BBS should always be tappered after
prolonged use.
 Not useful in variant angina.

24.  Nicorandil-an arterial & venous dilator.
 Opening of the ATP sensitive K+ channels
=efflux of K+ =hyperpolarisation & so
relaxation of the vascular smooth muscles.
 Also acts through NO like Nitrates.
 expensive
 Has LA & does not cause tolerance.
 S/es =Headache,flushing,palpitation,dizziness &
hypotension.
 Pinacidil is = to Nicorandil & is useful in AP&
HTN.

25.  Dipyridamole :coronary vasodilator but it
diverts blood from ischaemic zone &so not
beneficial. (used in platelet aggre. Prevention)
 Aspirin ;long term admini. Of a low dose for
preventing MI.
 Trimetazidine :a CCB claimed to have a
protective effect on the ischaemic
myocardium & to maintain left ven. Function.
 Used in exertional angina - 20 mg TDS.